Effectiveness of non-pharmacological interventions for treating post-stroke depressive symptoms: Systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To compare the effectiveness of non-pharmacological interventions on depressive symptoms in people after stroke. DATA SOURCES: A literature search was performed through databases from January 2000 to August 2018: MEDLINE; CINAHL Plus; Scopus; Academic Search Complete; Cochrane Central Register of Controlled Trials; Scopus; and Library, Information Science and Technology Abstracts. Search terms included depression, stroke, non-pharmacologic, and intervention. STUDY SELECTION: We included randomized controlled trials comparing non-pharmacological interventions to controls for depressive symptoms in people after stroke. Of 1703 identified articles, 22 trials were included in narrative synthesis, of which 13 were eligible for meta-analysis. DATA EXTRACTION: Two reviewers extracted characteristics of participants, interventions, and results from all included trials. DATA SYNTHESIS: Thirteen interventions were categorized into four types: complementary and alternative therapy (five trials, n=228), exercise (four trials, n=263), psychosocial therapy (two trials, n=216), and multifactorial therapy (two trials, n=358). Overall beneficial effects of non-pharmacological interventions on depressive symptoms were found both post-intervention (effect size [ES] = -0.24, 95% confidence Interval [CI]: -0.37 to -0.11, p < 0.05) and at follow-up (ES = -0.22, CI: -0.36 to -0.07, p< 0.05). We found individual beneficial effects for complementary and alternative therapy (ES = -0.29, CI: -0.55 to -0.02, p < 0.05) and psychosocial therapy (ES = - 0.33, CI: -0.60 to -0.06, p < 0.05) post-intervention. CONCLUSIONS: Complementary and alternative therapy and psychosocial therapy appear to be promising strategies for improving post-stroke depression. Future studies target  a personalized approach for people with specific conditions such as cognitive impairment.

Cognitive impairments and mood disruptions negatively impact instrumental activities of daily living performance in the first three months after a first stroke.

BACKGROUND: Cognition and mood play crucial roles in post-stroke recovery; however, the stroke literature is unclear as to how impairments in both domains influence performance of instrumental activities of daily living (IADL). OBJECTIVE: (1) Evaluate the extent to which mood and cognition at two weeks post-stroke predict performance three months post-stroke. (2) Assess performance differences in patients with impairments in both cognition and mood to patients with impairments in either cognition or mood. METHODS: Inpatients with a first-ever ischemic or hemorrhagic stroke were assessed at 2 weeks (n = 52) and at 3 months (n = 41) post-stroke. Patients completed a battery of neuropsychological tests, self-report measures and performance-based tests. Cognitive impairments and mood disruptions were assessed at 2 weeks and three months and IADL performance, as assessed by the Executive Function Performance Test, was evaluated at three months. RESULTS: Complete data from the 41 patients assessed at both time points were analyzed. Regression analysis showed that composite cognition and composite mood variables at two weeks post-stroke predicted 48% of the variance in IADL performance at three months (F3,37 = 12.04; adjusted R(2) = 0.48, P < 0.001). Statistically significant differences were found in performance scores for patients with a single impairment (M = 7.86, SD = 7.81) and for those with impairments in both mood and cognition (M = 19.2, SD = 13.2) (t(39) = - 3.41, P = 0.008). CONCLUSION: The results of this study suggest that cognitive and mood impairments at two weeks post-stroke are important predictors of performance in complex activities required for full independence at home and should be routinely assessed in stroke rehabilitation.

Distance from home to hospital and thrombolytic utilization for acute ischemic stroke.

Treatment of acute stroke with thrombolytic therapy has been limited because of the narrow treatment window. Distance from home to hospital may affect arrival time and likelihood of receiving thrombolytic therapy for acute stroke. The present study included stroke subjects seen at Barnes Jewish Hospital in 2006-2007, residing in St Louis City/County, who were at home at the time of the stroke (n = 416). A network distance was calculated by mapping the best route from each subject's home to the hospital on a street network grid. Patients were grouped by distance into quintiles, and the group living the closest (group A, first quintile) was compared with the remainder of the cohort (group B). Outcomes of interest were rate of arrival within 3 hours of stroke onset (timely arrival) and rate of thrombolytic administration. The relative rate (RR) of each outcome was calculated for group A versus group B. A multivariate model of thrombolytic administration was created correcting for potential confounders. There was no difference in timely arrival between groups. The rate of thrombolytic administration was 13/100 for group B and 23/100 for group A, for an RR 0.55 (95% confidence interval [CI], 0.31-0.097) for group B versus group A. In the multivariate model, only National Institutes of Health Stroke Scale score was a significant confounder. The adjusted RR of thrombolytic treatment was 0.59 (95% CI, 0.34-0.99) for group B versus group A. Our data indicate that patients living in close proximity to the hospital are more likely to receive thrombolytic therapy for stroke compared with those living farther away. This finding cannot be explained by earlier arrival time.

Rehabilitation after stroke: current state of the science.

Stroke rehabilitation is evolving into a clinical field based on the neuroscience of recovery and restoration. There has been substantial growth in the number and quality of clinical trials performed. Much effort now is directed toward motor restoration and is being led by trials of constraint-induced movement therapy. Although the results do not necessarily support that constraint-induced movement therapy is superior to other training methods, this treatment has become an important vehicle for developing clinical trial methods and studying the physiology underlying activity-based rehabilitation strategies. Other promising interventions include robotic therapy delivery, magnetic and electrical cortical stimulation, visualization, and constraint-driven aphasia therapies. Amphetamine has not been demonstrated to be effective, and studies of other pharmacologic agents are still preliminary. Future studies will incorporate refinements in clinical trial methods and improved activity- and technology-based interventions.

Resting interhemispheric functional magnetic resonance imaging connectivity predicts performance after stroke.

OBJECTIVE: Focal brain lesions can have important remote effects on the function of distant brain regions. The resulting network dysfunction may contribute significantly to behavioral deficits observed after stroke. This study investigates the behavioral significance of changes in the coherence of spontaneous activity in distributed networks after stroke by measuring resting state functional connectivity (FC) using functional magnetic resonance imaging. METHODS: In acute stroke patients, we measured FC in a dorsal attention network and an arm somatomotor network, and determined the correlation of FC with performance obtained in a separate session on tests of attention and motor function. In particular, we compared the behavioral correlation with intrahemispheric FC to the behavioral correlation with interhemispheric FC. RESULTS: In the attention network, disruption of interhemispheric FC was significantly correlated with abnormal detection of visual stimuli (Pearson r with field effect = -0.624, p = 0.002). In the somatomotor network, disruption of interhemispheric FC was significantly correlated with upper extremity impairment (Pearson r with contralesional Action Research Arm Test = 0.527, p = 0.036). In contrast, intrahemispheric FC within the normal or damaged hemispheres was not correlated with performance in either network. Quantitative lesion analysis demonstrated that our results could not be explained by structural damage alone. INTERPRETATION: These results suggest that lesions cause state changes in the spontaneous functional architecture of the brain, and constrain behavioral output. Clinically, these results validate using FC for assessing the health of brain networks, with implications for prognosis and recovery from stroke, and underscore the importance of interhemispheric interactions.